Sylvia Becker-Dreps, MD, MPH, is director of the UNC Program in Nicaragua within the UNC Institute for Global Health & Infectious Diseases. She is an associate professor in the Department of Family Medicine in the UNC School of Medicine, and an associate professor in the Department of Epidemiology in the UNC Gillings School of Global Public Health. She is also an associate director of the Office of International Activities in the UNC School of Medicine. In this interview, she shares why she became a physician, what drew her to research childhood infectious diseases in Nicaragua, and how she unwinds when she’s not at work.
Q. What drew you to a career in medicine?
A. The inequalities in health based on geography, especially for children, drew me to a career in medicine. Diarrhea is the second leading cause of death in children worldwide. Pneumonia is the first. It is inherently unfair that a child can die of those diseases in another country, but not here in Chapel Hill. All people deserve access to life-saving care.
Q. How did you first become involved with care and research in Nicaragua?
A. I went to medical school at Duke. In my third year, I worked on malaria vaccine research and I thought about a career working for Doctors Without Borders. I chose family medicine because it would provide me with the broadest clinical skillset. But, I started having a family, and then going to Sudan with a nursing infant no longer seemed like such a good idea; so instead, I ended up working in rural NC.
I repaid my medical school loans by working in Caswell County, North Carolina, where I saw a primarily Spanish-speaking population. I was also involved in the North Carolina Farmworker Health Program, which provides primary care services to farmworkers around the state. After paying off my loans, I then came to UNC for a research fellowship and I earned an MPH. I then started to realize that research was a great way to have an ongoing impact on global health, but would still allow me to have some time to support our growing family.
In 2007, I began working with Doug Morgan, who is a gastroenterologist now based at the University of Alabama. He had been involved with clinical teams that provided gastroenterology and cardiology care in León, Nicaragua. Then, they expanded to a research collaboration. At first, I thought I would return to malaria research like I had done in medical school. But with two young children, frequent trips to sub-Saharan Africa did not seem feasible. But Nicaragua is two hours by plane from Miami. And I speak Spanish because my mom is from Argentina. Nicaragua seemed like a good fit for me to conduct my global health research and improve access to healthcare for children there.
UNC faculty Elizabeth Stringer. MD, (right) and Sylvia Becker-Dreps, MD, MPH, (left)
during travels to the UNC Program in Nicaragua to contribute to research efforts to understand Zika infections.
Q. What research is done at the UNC Program in Nicaragua?
A. When I first went to Nicaragua, I saw they were giving children the oral rotavirus vaccine, and introduced the vaccine about the same time as my clinic in the US. They were one of the first low- and middle income countries (LMIC) to provide the vaccine. But, although Nicaragua was collecting a lot of data from their clinics and hospitals, it did not seem that anyone was analyzing it. Some of our early research showed that the vaccine was not as effective in Nicaragua as compared to the US. The same thing was being seen in other LMICs. I became interested in understanding why the vaccine is less effective.
We have found a combination of factors which may be contributing, including interference from the maternal immune system, a condition of the intestines called environmental enteropathy, and even genetic factors. This information may lead to ways to make the rotavirus vaccine more effective. And we are also doing research on other causes of diarrhea, such as norovirus and sapovirus. Currently, norovirus is more of a problem for children in Nicaragua than rotavirus. We are working on studying the development of immunity to these infections and how they are transmitted. All of this research is only possible due to our collaborators. I work with the talented research teams at the University of Nicaragua (UNAN) to do the field epidemiology, but then we connect with other scientists for their immunology and molecular virology expertise, like Ralph Baric, PhDand Lisa Lindesmith at UNC, and other colleagues at the U.S. Center for Diseases Control and Prevention.
We also investigate Zika. In 2015, I was in a taxi in León talking about dengue and the other passenger in the taxi asked me if I had heard of Zika. I didn’t realize that I would end up spending the next few years studying the virus. Through the childhood diarrhea work, we have built the lab capacity in Nicaragua to study Zika. When it really emerged in 2016, we applied for funding through the UNC Provost’s Office and got to work. I worked with colleagues to recruit women around the peak of the Zika epidemic in 2016. We worked really fast because we were racing to understand the virus. For the first few years, no one was getting paid to do this work. It has been incredible to see the research community come together over Zika.
Q. Are there any new developments into Zika?
A. UNC is working on several projects to better understand Zika. With Elizabeth Stringer, MD, MSc, of the UNC Department of Obstetrics and Gynecology’s Division of Global Women’s Health and preventive medicine resident, Shiara Ortiz-Pujols, we are following a cohort of 450 pregnant women, half of whom were pregnant during the 2016 Zika outbreak in Nicaragua. We believe that 60 percent of the Nicaraguan population was exposed to Zika. But in this study, 225 women were pregnant during the Zika outbreak and 30 percent of these women were exposed to Zika. We are following them and their babies to see what is happening. We’ve learned how to better diagnose Zika, thanks to a collaboration with Aravinda de Silva, PhD, MPH, of the UNC Department of Microbiology and Immunology. Zika looks a lot like dengue, so he and his lab had the expertise to design an algorithm to identify Zika during pregnancy.
And then Elizabeth and I are following the babies for developmental outcomes. We know that Zika causes microcephaly. But what if your baby looks fine? Is everything really okay or are there other developmental outcomes we need to be mindful of? We are following these babies for years as the enter into pre-school.
Natalie Bowman, MD, MPH, of the UNC Division of Infectious Diseases, is leading another Zika study in Nicaragua to understand the clinical picture of Zika and how long the virus lives in different body compartments. We have collected saliva, blood, urine, semen, vaginal fluid and breast milk samples from patients with Zika, to understand how long the virus persists and could be spread. We also want to know if Zika affects male fertility. We know in mice, Zika causes male mice to become infertile. Natalie has partnered with UNC urologist Matt Coward to study Zika and male fertility.
Q. What research questions would you like to answer in the future?
A. In addition to better understanding Zika, I want to know more about sapovirus. It is related to norovirus and very common in Nicaragua. In fact, sapovirus is the second leading cause of diarrheal disease in children worldwide. We are following a birth cohort of 400 children until they are three-years-old. We capture their stool and study it when they have diarrhea. We want to know if you can become infected with sapovirus again, how this virus is transmitted, and how immunity develops.
There are also several norovirus vaccine candidates coming into clinical trials and that is exciting. A norovirus vaccine would not only benefit children worldwide, but also college students and nursing home residents.
Sylvia Becker-Dreps, MD, MPH, center, is the co-principal investigator for NEED.
Q. Tell me a little about why you applied for funding for the NEED training.
A. There is no opportunity in Nicaragua for people to earn a PhD in science. In the past, the Swedish government provided funding for young scientists to earn PhDs, but that funding has ended. UNC filled that gap. With the help of Kathryn Salisbury, MPH, manager of fellowship and training programs in the UNC Institute for Global Heath & Infectious Diseases, Steve Meshnick, MD, PhD, and I applied for a D43 grant from the NIH to provide early investigators in Nicaragua the opportunity to move from a master’s degree to earning a PhD in-country through UNAN.
We received the funding in 2018. NEED stands for the Nicaraguan Emerging and Endemic Diseases training program. We received $1.2 milllion from the NIH for five years. We will provide PhD training in infectious diseases epidemiology at UNC to two young investigators from UNAN. We will start a biomedical sciences PhD program in León for five trainees. This is the first science PhD training program at UNAN. And we will host an annual research seminar to foster professional growth and short-term learning opportunities.
This really opens up doors to young investigators in Nicaragua who otherwise would never be able to earn a PhD in-country. Having a PhD opens doors for future research opportunities for these early career researchers. These PhD students are co-mentored by UNC and UNAN faculty. So many UNC faculty have been so supportive of this program and so giving of their time to make this NEED training program work.
Q. What is your role with the UNC Office of International Activities?
A. I am one of three clinical faculty who mentor students as part of the OIA. I support medical students and residents who are interested in pursuing careers in global health, especially if they have a Latin American focus. Our office also provides travel funding for these experiences. Six medical residents receive scholarships through the OIA each year and they are paired with a mentor and a topical mentor to complete a research project. It is an intense global health experience. Starting this year, we are rolling out a global health concentration for medical students and helping them complete a scholarly project.
Q. What do you do when you’re not at work?
A. I like to garden and started doing that when my three children were younger. We can grow everything in USDA Zone 7, from Asian persimmons to lettuce to Okra. I can ketchup at the peak of the tomato season. We also like to bike as a family. My husband and my son are mountain bike fanatics. I get left in the dust.
